Do People With Celiac Need Gluten-Free Probiotics?

Gluten Free Probiotics For Celiac Disease and Gluten Sensitivity

• Gluten Free Probiotics|
• Probiotics Help a Gluten Free Diet Work|
• Gut Microbiome and Celiac|
• Three Steps to Improve Gastrointestinal Symptoms|
• Probiotics for Celiac Disease|

If you have celiac disease or non-celiac gluten sensitivity (NCGS), you may be wondering if you need a “gluten-free probiotics” label on your dietary supplement. You will be happy to know that probiotics are already gluten free. But, what if you are still having gastrointestinal symptoms on your strict gluten free diet? This article will help you assess why that might be happening and how probiotics can help.

Gluten Free Probiotics

Let’s start off with the good news: You can take probiotics if you are gluten intolerant or have celiac disease, as probiotics are already gluten free.

You should not need to seek out probiotics labeled “gluten free” because there is virtually no reason for gluten to be in probiotics. Live microorganisms do not contain gluten, and fillers in probiotics should also be gluten free. No needed filler would contain gluten. 

However, research shows that about 50% of probiotics do contain traces of gluten from manufacturing [1]. In fact, two of the brands labeled as “gluten free probiotics” had higher traces than those not labeled gluten free. This is why some people claim we need gluten free probiotics. However, the trace amounts are so low that you would have to take huge doses of probiotics to cause any damage. 

In one study, on 22 commonly purchased probiotics, probiotics with trace amounts of gluten had less than 20 parts per million [2]. The Food and Drug Administration (FDA) considers an item able to be certified gluten free if it has less than 20 parts per million [2], meaning these were gluten free. For reference, celiac patients only develop intestinal damage at 10 mg of gluten, which you could not get from probiotics [3].

Not only are probiotics safe to take if you have celiac disease or non-celiac gluten sensitivity. Probiotics can help decrease symptoms and improve the immune health of your gut. 

Probiotic Supplements Make Gluten Free Diets More Effective

Probiotics can be an important part of improving digestive health for people with celiac disease and non-celiac gluten sensitivity.

In fact, studies show that a gluten free diet combined with probiotics can not only improve symptoms of celiac disease but also decrease inflammatory markers and improve the gut microbiome better than just a gluten free diet alone [4, 5, 6, 7, 8, 9].

• A 2020 meta-analysis with more than 5,000 patients found that probiotics improved gastrointestinal symptoms in celiac patients by an average of 228.7% on certain symptom scales [10].
• For kids with celiac disease, taking probiotics while eating a gluten free diet reduced inflammation of the digestive system and changed the gut microbiome to resemble those of healthy individuals [5].
• In another study, severity of symptoms was reduced 16%-20% in the group taking probiotics as compared to the placebo group [4].
• One study even found that probiotics seemed to improve the immune system of kids genetically predisposed to celiac and protect them from developing celiac disease, even though they ate gluten [7].
• Multiple studies on celiac patients who took probiotics with a gluten-free diet showed an improved microbiome, by restoring healthy gut microbiota [11, 12].
• Probiotics may help break down gluten, in specific the gliadin peptide (a peptide found in gluten that causes inflammation), as well as decrease inflammatory cytokine markers (a sign of inflammation) that contribute to celiac disease [13, 14].

Probiotics can help celiac disease patients and those with gluten intolerance feel better and restore their gut microbiome. They are also helpful if you have any underlying gut dysbiosis (an imbalance of good bacteria to bad bacteria in the gut) along with having celiac disease. 

You may wonder if one probiotic strain works better than another. A few different strains, such as lactobacilli and bifidobacteria have been used in research, but no one has proven to be the most effective. In fact, the best results have been found when using multiple strains of probiotics rather than just one [4, 14].

The Role of The Gut Microbiome in Celiac Disease

First, let’s quickly go over what celiac disease and non-celiac gluten sensitivity (sometimes called gluten intolerance) are.

Celiac disease is an autoimmune disorder where the gluten proteins cause the immune system to activate and attack the walls of the small intestines. This results in intestinal permeability, or a reduced barrier between the gut and the rest of the body, lowers production of enzymes that help digest food and limit your ability to absorb nutrients from your food. You can see this inflammation, the breakdown of the walls of the small intestines, in testing with a biopsy [15].

Non-celiac gluten sensitivity does not show inflammation to the small intestines on biopsy. However, people still get gastrointestinal and systemic inflammation symptoms after eating gluten [16]. This may be because the inflammatory response is too low to test, but still high enough to cause symptoms.

The symptoms of celiac disease and non-celiac gluten sensitivity are similar but include various abdominal and non-digestive symptoms. Some symptoms include bloating, abdominal pain, diarrhea, joint pain, eczema, weight loss, or headaches.

What does the gut microbiome have to do with celiac disease and gluten sensitivity?

Some people who go gluten-free do not get relief from their symptoms. This can happen for a few reasons. First, people with celiac disease tend to also have gut dysbiosis that can cause symptoms [17, 18, 19, 20, 21]. Second, there is often an additional underlying issue causing the gut microbiome imbalance, most often SIBO (small intestinal bacterial overgrowth), which we will discuss later.

In addition, a 2020 meta-analysis of 19 observational studies (more than 3 million participants) found that infections and/or antibiotics early in life seemed to increase the risk of developing celiac disease. This suggests that gut dysbiosis and impaired intestinal immunity (a large part of our immune system is in the gut) contribute to celiac disease [22].

Celiac and SIBO

People with celiac disease or non-celiac gluten sensitivity may have gut dysbiosis due to an immune response to gluten and even a gut infection. 

Both children and adults with celiac disease often have increased short-chain fatty acids in their stools, which suggests that people with celiac disease may have bacterial overgrowth in their small intestines [17, 23].

The most common form of bacterial overgrowth in celiac patients is SIBO [24]. Symptoms of SIBO such as gas, bloating, stomach pain, and diarrhea are often improved on a low-FODMAP diet. This is why many people with celiac disease feel better if they go on a gluten free, low-FODMAP diet.

In a low-FODMAP diet, highly fermentable carbohydrates (oligosaccharides, disaccharides, monosaccharides and polyols) are removed, which means that bad bacteria has less to feed on and it starts to die off. These are foods such as garlic, onions, broccoli, cabbage, beans, apples, mangoes, rye, and milk.  

If you do find you have an issue with FODMAPs, you will want to stay away from prebiotics added since prebiotics are often made from non-digestible oligosaccharides, which are the “O” in FODMAP. Prebiotics are fibers that fuel bacteria, including probiotics. They are often taken with or included in probiotics to give the probiotics something to feed on, but they also give all the other bacteria in your gut food as well and can cause a problem if you have SIBO.

A generally good dose of probiotics for SIBO is around 100 million-1 billion colony forming units (CFUs) a day. This is a typical amount for one daily dose of regular strength probiotics [25, 26].

However, the low-FODMAP diet is often not enough to resolve SIBO. Once many people start eating FODMAPs again, their symptoms come back. 

This is why you may want to work with a healthcare professional if you suspect you have SIBO, especially if you have tried a low-FODMAP diet for a few weeks and felt better. You may need testing, often a simple breath test, to confirm SIBO or see if something else is going on with your digestive tract. Treatment for SIBO usually involves conventional antibiotics or herbal antimicrobials. 

SIBO and Other Gut Imbalances Often Occur Alongside Celiac

In celiac patients, SIBO can be fairly common. In fact, the dysbiosis in celiac patients was found to be similar to that of IBS patients. Up to 78% of IBS patients have SIBO [27].

In one interesting study, 15 celiac patients who were on a gluten free diet but still had remaining symptoms were tested for gut infections and imbalances. They found that 10 of the 15 patients had SIBO, two others had parasites, and two were lactose intolerant [28]. They then treated each group for each of these underlying conditions, and all of the patients became symptom free!

Three Steps to Improve Gastrointestinal Symptoms

If you are gluten free and still experiencing digestive symptoms, follow these three steps:

1. Start taking probiotics, if you are not already doing so. Do this for a month and see if you improve. If not, move to step two.
2. Keep taking probiotics, and also follow a low-FODMAP diet for two weeks and see if your symptoms improve. If they do improve, this is a good indication you may have a gut imbalance, most likely SIBO. If you do not improve, this is also an indication that you might have gut imbalance or a parasite. In both cases, you should move on to step three.
3. Work with a healthcare professional to check for gut infections such as SIBO, parasites, or any other condition that may be causing additional symptoms.

These steps should help you regain digestive balance or figure out if you have an additional underlying condition that needs to be addressed. 

Use of Probiotics When Addressing Celiac Disease 

Thankfully, probiotics are safe to use if you have celiac disease or non-celiac gluten sensitivity because they do not contain gluten. Probiotics with a gluten free diet are typically the most effective way to improve the gut microbiome and relieve gastrointestinal symptoms such as bloating, pain, and constipation or diarrhea. 

It is definitely worth adding a daily probiotic into your routine with your gluten free diet and see if it helps. If it does not help, you have more helpful information about your health and you can then try a low-FODMAP diet to gain more insight. 

You should then look for a healthcare professional who can help you look at any underlying issues that may be contributing to your symptoms and resolve any food intolerances, lack of digestive enzymes, histamine intolerance, or gut infections.

If you are concerned you may have an underlying issue contributing to your symptoms, our clinic is ready to help you. You can fill out our patient request and we will get you started improving your gut health.